lnfoCard#: PBMT-GEN-042 Rev. 07 Effective Date: 01 Dec 2018

PEbIATRIC BLOOD ANb MARROWTRANSPLANT PROGRAM

DOCUMENT NUMBER: PBMT-GEN-042

DOCUMENT TITLE:Infusion of Granulocytes

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Revision: 07 Vault: PBMT-General-rel

Status: Release Document Type: General

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Creation Date: 31 Oct 2018 Release Date: 01 Dec 2018

Effective Date: 01 Dec 2018 Expiration Date:

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MOORE171

Number: PBMT-GEN-042 Rev 06

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MOORE171

Number: PBMT-CCR-209

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PBMT-GEN-042INFUSION OF GRANULOCYTES

1 PURPOSE

1. 1 To outline the procedure and nursing responsibilities for administeringgranulocytes to the pediatric blood and marrow transplant (PBMT) patient.

2 INTRODUCTION

2. 1 Granulocytes, a type of blood product, may be indicated in the setting ofneutropenia and/or infection and are administered as an action to provide thepatient with circulating granulocytes.

2. 2 Blood products:

2. 2. 1 May be administered to pediatric patients through a central line orperipheral line. If a central line is not available, in pediatrics, a 24gauge or larger peripheral catheter size is preferred.

2. 2. 2 May be infused alone or with normal saline solution.

2. 3 Granulocyte Special Precautions:

2. 3. 1 ABO incompatible products must be plasma depleted and/or red bloodcell (RBC) depleted before administration.

2. 3.2 If possible, avoid transfusions of other bloods products with 4 hours ofgranulocyte infusions.

2. 3. 3 Do not infuse granulocytes within 4 hours (pre and post) of anyamphotericin containing product (Amphotericin B, ABLC, andAmbisome).

2. 3.4 Do not infuse granulocytes on pump that has a pumping mechanism thatcould crush cells (i.e. volumetric pump). Do not use Plum A+ orOMNIFLOW PUMP.

2. 3. 5 Granulocytes are NOT compatible with dextrose-containing solutions.

2. 3. 6 Infuse over a minimum of 2 hours or per MD instructions.2. 3. 7 Do not leukoreduce!

2.3. 8 All granulocyte products must be irradiated prior to infusion.Nursing must verify that the product has an irradiation sticker attached.

2. 3. 9 Requires premedication prior to infusion.

3 SCOPE AND RESPONSIBILITIES

3. 1 Interdisciplinary: requires an order by an physician or designee in the electronicmedical record

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lnfoCard#: PBMT-GEN-042 Rev. 07 Effective Date: 01 Dec 2018

3.2

3.3

3.4

Registered nurses (RNs) may administer granulocytes after successful completionofthe blood administration test and demonstration of clinical competency withtheir preceptor.

RNs caring for PBMT patients must re-validate their clinical competency toadminister granulocytes on an annual basis.

Other licensed personnel (advanced practice providers or physicians) mayadminister blood products after demonstration and validation of clinicalcompetency.

DEFINTIONS/ACRONYM8

4. 1 PBMT Pediatric Blood and Marrow Transplant

Personal Protective Equipment

Red Blood Cell

Registered Nurse

Stem Cell Laboratory

Intravenous

4.2

4.3

4.4

4.5

4.6

PPE

RBC

RN

STCL

IV

5 MATEMALS

5. 1 The Standard 170 or 180^ blood administration set (Micron Filter) should be usedfor each infusion.

5.2 Normal Saline Flush.

5. 3 Gloves (non-sterile).

5. 4 Alcohol Pads.

5. 5 Granulocytes to infuse by syringe pump as directed by physician.

6 EQUIPMENT

6. 1 Must use Alaris syringe pump with Medex 60-inch Extension Set Apv 2. 4 mL(product # 5360225).

7 SAFETY

7. f Personal Protective Equipment (PPE) must be worn when handling any bloodproducts.

8 PROCEDURE

8. 1 Patient Assessment

8. 1. 1 Assess patient for prior infusion reactions. Notify the physician ordesignee if the patient has a known history of infusion reactions.

8. 1.2 Assess the central venous line or peripheral intravenous (IV) site forpatency.

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8.2

8. 1.3

8. 1.4

Assess and record vital signs pre-administration, 10-20 minutes intoinfusion, and at completion of infusion.

Observe the patient continuously for the first 5 minutes of infusion andthen hourly for signs and symptoms of infusion reaction:

8. 1.

8. 1.

8. 1.

8. 1.

8. 1.

8. 1.

8. 1.

8. 1,

8. 1.

. 4.1

. 4.2

. 4.3

. 4.4

. 4.5

. 4.6

. 4.7

. 4.8

. 4.9

8. 1.4. 10

fever

chills

anaphylaxis

hypotension

tachycardia

dark or red urine

rash, hives

back pain

shortness of breath

urticaria

Obtaining and Verifying Blood Products

8.2. 1 The Stem Cell Laboratory (STCL) staff person will notify the care nursethat granulocytes are available for infusion. The care nurse will confirmthat the patient is able to receive the infusion.

Granulocytes will be transported from the Stem Cell Laboratory to thepatient care unit.

8. 2.2

8. 2.3

8.2.4

8. 2.5

8.2.6

8.2.7

Administer pre-medications, if ordered, when granulocytes are availableand patient is ready for infusion.

Ensure there are emergency medications available as ordered.

The STCL staff will coordinate delivery of the product to the patientcare area.

When granulocytes arrive on the patient care unit, the nurse will verifythat the product has been irradiated by checking the sticker on product.If product is NOT irradiated, notify the physician or designeeimmediately and DO NOT GIVE PRODUCT.

The product should be administered immediately on arrival to the careunit. If the patient is not ready within 10 minutes of product arrival,place the product on the rotator at a speed of 6-8 rotations per minute atroom temperature. See related procedure: PBMT-GEN-043 Use ofLab-Line Maxi Rotators.

8.2.8

8.2.9

When ready for infusion, draw product into lor 2 of the 60 mL syringesand place in syringe pump with Medex tubing.

Verify all identification information at the bedside by two licensedprofessionals (one a RN) upon receipt of the product. Verify thefollowing identification information:

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8. 2. 9. 1 Patient's name and medical record number on armband must

match the label on the product bag.

8.3 Complete M-03 Infusion Request Form, photocopy and place a copy in medicalrecord file by HUC desk and send a copy to patient's red chart.

8. 4 Special Consideration:

8.4. 1 Make every effort to start infusion of the granulocyte products within 30minutes of receipt of product from the Stem Cell Laboratory.

8. 5 Don Gloves.

8. 6 Using aseptic technique draw Granulocyte product into a 60 mL syringeconnected to bag.

8.7 Prime the tubing.

8.8 Clear the infusion line with Normal Saline.

NOTE: Medications or solutions other than Normal Saline (0. 9%) may not beadded to blood products or infusion lines.

8. 9 Clean the central venous line catheter cap with alcohol prep pad.

8. 10 Connect tubing to the patient's infusion access and administer via syringe pump.DO NOT INFUSE ON PLUM A+ OR OMNIFLOW PUMP.

8. 11 Infuse granulocytes cells at a rate specified by the medical order, over no less than2 hours.

8. 12 Record volume ofgranulocytes transfused on Intake and Output Form.

8. 13 All infusions shall be traced from infusion bag to tubing insertion point ofcatheter to verify correct fluid is infusing into correct port with each bag or tubingchange, and with each change in caregiver.

8. 14 Flush the patient's infusion access as per central line or peripheral IV protocol.

8. 15 Place empty blood product bags, syringes and tubing in hazardous wastecontainer.

8. 16 Patient Monitoring

8. 16. 1 Follow Duke University Hospital Process Standard for Blood ProductsAdministration.

8. 17 Documentation

8. 17. 1 Document infusion/procedure in the electronic medical record.

8. 17.2 Reportable Conditions are listed in Table 1 .

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Table 1. List ofReportable Conditions and Corresponding ActionsReportable ConditionHypotensionAnaphylaxisChillsTemperature Elevation > 1 degreeCelsiusDark or red urine

TachycardiaDyspneaBack painRashHives (Urticaria)

Action

STOP THE INFUSION and notify thephysician or designee. Administerinterventions as ordered.

Stop infusion. Contact the physician ordesignee regarding antihistamineadministration.

9 RELATED DOCUMENTS/FORMS

9. 1 Hematopoietic Progenitor Cell Infusion Request Form (M-03)

9.2 PBMT-GEN-043 Use of Lab-Line Maxi Rotators

10 REFERENCES:

10. 1 Accreditation Requirements Manual of the American Association of BloodBanks, Current Edition

10.2 The Duke Hospital Blood Administration Policy

10.3 The AABB Technical Manual, Current Edition

11 REVISION HISTORY

Revision No.

07Author

SallyMcCollum

Description of Change(s)Items under Introduction Section regrouped together forbetter document flow.

Acronyms defined throughout.

"Epic" changed to electronic medical record for longevityof document.

Table 1 was given a title: List ofReportable Conditionsand Corresponding Actions

Section 2.3 additional precaution statement added:Ifpossible, avoid transfusions of other bloods products with4 hours of granulocyte infusions.

Section 2.3 additional precaution statement added:Requires premedication prior to infusion.

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lnfoCard#: PBMT-GEN-042 Rev. 07 Effective Date: 01 Dec 2018

Revision No. Author Description of Change(s)

Section 8.2. 7: referred reader to associated procedure -"See related procedure: PBMT-GEN-043 Use ofLab-LineMaxi Rotators. "

Section 8. 2. 7 restructured for better flow: The productshould be administered immediately on arrival to the careunit. If the patient is not ready within 10 minutes ofproduct arrival, place the product on the rotator at a speedof 6-8 rotations per minute at room temperature. Seerelated procedure: PBMT-GEN-043 Use of Lab-LineMaxi Rotators.

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InfoCardff: PBMT-GEN-042 Rev. 07 Effective Date: 01 Dec 2018

Signature Manifest

Document Number: PBMT-GEN-042

Title: Infusion of Granulocytes

Revision: 07

All dates and times are in Eastern Time.

PBMT-GEN-042 Infusion of Granulocytes

Author

^Name/Sigiiature__...l.JJl^..Sally McCollum (MOORE171)

Medical Director

Date Meaning/Reason

09 Nov 2018, 11:56:19 AM Approved

Name/Signature

Joanne Kurtzberg(KURTZ001)

Quality

Title Date Meaning/Reason

09 Nov 2018, 10:06:05 PM Approved

Name/Signature Title

Bing Shen (BS76)

Document Release

Date

12 Nov 2018, 11:22:06 AM ApprovedJ- Meaning/Reason

I Name/SignatureBetsy Jordan (BJ42)

Title _l-2.aJ£- I Meaning/Reason

19 Nov 2018, 10:48:29 AM Approved

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